An overview of the Essex pilot on pharmacy's role in NHS Direct, which comes into full operation on March 1, 2000, was given by Mr Ash Pandya at a conference held as part of the local pharmaceutical committee support programme of the Pharmaceutical Services Negotiating Committee, in Milton Keynes, on December 6
The main advantages to community pharmacy of a role in NHS Direct were greater integration with primary care and acknowledgement of the pharmacist's professional clinical skills, Mr Pandya told the conference. The main direct financial attraction of the scheme would come from increased "footfall" in the pharmacy.
Mr Pandya mentioned that, when Ms Gisela Stuart (Under Secretary of State for Health) had visited the Essex pilot, one point she had picked up had been that 24 per cent of all visits to pharmacies did not end with a sale. That had come as a shock to her, and she had since repeated the statistic elsewhere on her travels.
Mr Pandya added that the Government was keen to see the Essex pilot successful and to have pharmacy linked with NHS Direct. One visitor to the pilot had been Mr Robert Hill from the Prime Minister's policy unit, who had emphasised the need for quality assurance. Mr Pandya agreed that a quality assurance programme was important. There should be a standard approach across the country so that patients got the same kind of advice whether in North Essex or North Yorkshire.
The Essex pilot, Mr Pandya said, had been operating since February 1, and had included Barking and Havering since November 1. The pharmacy project was aimed specifically at encompassing all 289 pharmacies in North Essex and South Essex and the 80 pharmacies in Barking and Havering. The project would be open to all pharmacies, all pharmacy contractors and all pharmacists, including locums, and they were being encouraged to take part.
Outlining the workings of NHS Direct, Mr Pandya said that the initial call from the public was handled by a "call taker" who, as well as being able to switch the call to a nurse adviser, could also switch it to services dealing with hearing difficulties, language problems or emergencies (999). If the inquiry concerned medication, the call could if necessary be diverted to, or advice obtained from, the regional drug information service or poisons unit. If the query was symptom-based, the nurse adviser used the computerised Clinical Decision Support System (CDSS) to obtain a recommended "disposition" [NHS-speak for option]. She currently had three options: self-help advice, visit a general medical practitioner or visit an accident and emergency department.
In the Essex pharmacy project there was also a fourth disposition, to visit a pharmacy. Having gone through the CDSS, the nurse would be prompted by the system to recommend to the caller that the most appropriate course of action to treat the symptom presented was to visit a community pharmacy. The fourth disposition was concerned specifically with symptom-based inquiries and not with medication inquiries.
The Essex project on the fourth disposition would allow the profession to prove in a large, independently evaluated study how effective it was in dealing with symptom-based minor ailments. The evaluation would be by Sheffield university, which was doing the same for all NHS Direct. Most importantly, the study would show, among many other things, how cost-effective pharmacy could be to the new emerging NHS.
The Essex project had been approved early in 1999 by the NHS Direct central team, after which the CDSS algorithms had been reviewed to include the fourth disposition. All the algorithms - 248 guidelines - had been reviewed by a team led by Professor Alison Blenkinsopp (department of pharmacy education and practice, Keele university). Included in the team were practising and academic GPs and pharmacists and also a pharmacist consultant in public health, a data analyst and a management consultant.
Of the 248 guidelines studied, 68 had been changed - half from GP referral and half from home-care referral. The changes would provide 182 opportunities for pharmacy referral. The result of the project would, Mr Pandya hoped, have a tremendous impact on pharmacy from patients who would previously have visited a GP.
Depending on the search word the NHS Direct nurse put into the CDSS, the algorithm would take her through a series of questions that went in decreasing levels of severity of symptoms until she got a positive answer from the patient. If she reached level 4, the advice was to visit a GP within 72 hours; for level 5 it was to visit a GP in two weeks; and level 6 was home care.
The next question was how to decide which patients from these guidelines could be referred to community pharmacy. The criteria used were that the appropriate treatment was a medicine available only from a pharmacy or that significant additional advice would be available from a pharmacist. It could be that the previous disposition would have been home care, but the reviewer felt that in that situation there would be more benefit to be gained from obtaining a pharmacy medicine and advice from a pharmacist than simply to take paracetamol that the patient might have at home. Other criteria were that there was a low clinical risk associated with pharmacy referral or that the condition was one that was routinely dealt with by pharmacists.
To decide how the algorithms should be changed to refer to a pharmacy, the review team had created a template for levels 4, 5 and 6. The templates they designed had been scrutinised by every pharmacist and every practising GP on the panel until they had reached agreement on when to go to the fourth disposition. The questions leading to a fourth disposition referral were:
After all that, it could be decided whether to recommend pharmacy as a fourth disposition for a particular guideline.
Patients on the fourth disposition would have a reference number to be presented to the pharmacy on their visit. The pharmacist would have to complete, by ticking boxes, a basic evaluation form for sending to NHS Direct. Funding was being sought for the pharmacist's administrative role concerning the evaluation forms.
The Essex NHS Direct nurses were already being trained in the new system, Mr Pandya said. Lead nurses were visiting community pharmacies, and pharmacists were being invited to visit call centres at any time.
For pharmacists, invitations to training were going out that week. Pharmacists would not require any new clinical training; the training would be about NHS Direct, the role pharmacists could play and the role nurses played. It was expected that every pharmacist in the pilot area would be trained by March 1, 2000. The training was being organised jointly by the College of Pharmacy Practice, the National Pharmaceutical Association and the LPCs. It would be accredited by the CPP as continuing education.
The pharmacist training for the Essex NHS Direct project is being organised by the Centre for Pharmacy Postgraduate Education (among others) and not the College of Pharmacy Practice. The training will be accredited by the CPPE.